Toward a New Orthodontics
Until now, orthodontics has been based on a craft management model. There is a mechanical task to be done; we do it, retain it for a period of time, and dismiss the patient. It is time now to adopt a medical management model.
This point was brought forcefully home in a public television program on hip replacement. There is an even more mechanical quality to hip replacement than there is to orthodontic tooth movement, yet the posttreatment approach was vastly different.
The surgeon said that there were no guarantees-- that something could go wrong. The replacement parts could loosen, there could be bone deterioration-- but he was optimistic that the chances were in the 90th percentile that the replacement should last 15 years. Then he said, "It is my responsibility to monitor the patient's condition for the rest of her life, or mine."
Orthodontists, on the other hand, may show patients models after treatment and say, "Look at this great thing we have done together. We will retain this result for x number of years, following which I will dismiss you." We seek to write finis to the job, to end our obligation. It is with this scenario that we have established the idea that, once done, the job stays done; and that the cases that don't remain stable are the exception.
We have created our own problem by not wanting to admit that teeth can change position post-treatment. We have made orthodontics a transient service. Now, since we know that long-term stability is problematic, we have to rethink our professional goals and obligations and our relationships to our patients. We ought to adopt the medical approach.
We ought rather to be saying, "I will do my best to correct the problem. I am optimistic that the chances that this result will last in reasonably good health and appearance for 15 years are in the 60th, 80th, 90th percentile. It is my responsibility to see this patient for her lifetime, or mine, to check that the result is being retained or to check that changes that may occur are not detrimental to her dental and oral health and appearance, or to the health of the TMJ." That is a logical and responsible professional approach to post-treatment management of a morphological problem in a changing environment, and a better service.
It will be argued that such a plan would result in a post-treatment case load of thousands. This is true, even though the attrition of patients moving away or losing interest would reduce the number to some extent. The point is that we must get our priorities straight first, and then determine how to accomplish our mission. The extent of our responsibility is a philosophical problem. The resolution of a large case load is a management problem.
It may be that after 20 years a practice may be largely limited to post-treatment recalls. It might be questioned how an orthodontist could ever retire. Who would take over the obligation? There might be a need--imagine this--to train more orthodontists. There might be a joining of forces into a group post-treatment center. The problem is solvable, with benefits on all sides.
The average orthodontist is experiencing a downturn in case starts and income after 15 years in practice. The average practice is declining at a time when the orthodontist should be at the height of his or her abilities to serve. All that talent could be put to better use.
Meanwhile, there is a need to learn more about post-treatment stability and instability. Some orthodontists consistently get more stable results more often than others. Is it intuition? Are there some built-in standards of tooth position that are more often compatible with the physiologic environment? What are the long-term effects of permanent retention? Is it acceptable to hold teeth in positions from which they would move if they were released? One of the consequences of dismissing patients after treatment is that we do not have answers to those important questions. We have only fragmentary information about cases long out of retention.
Orthodontics has grown for the most part horizontally. We have achieved great facility in moving teeth and even in influencing growth to some extent. We now need to grow vertically and expand our horizons as an important health care service.